Group TherapyGroup Therapy

Dr Sabar Rustomjee

Adapted in part from Principles of Group Psychotherapy –

American Group Psychotherapy Association Inc

Authored by Robert L. Weber, Ph.D.,CGP, FAGPA

Email : www.agpa.org

What is a Group?

The existence of Group in our Minds.There is no such thing as an individual without a group. Just as we are not able to understand a melody if we listen separately to each note, so we are unable to understand different aspects of an individual if we isolate him / her from their groups of belonging.A group is defined by its task or function. Without a task focus it remains a collection of individuals.

Group Therapy

Group Therapy focuses on interpersonal learning:– It helps individuals get along in a more honest and authentic way with other

people.– It provides a support network for specific problems and challenges.

Analytic Group Psychotherapy (as distinct from all aspects of Group Therapy) provides the development of an awareness of both Conscious and Unconscious factors.

Uses of Group Therapy. It provides an opportunity to learn:

• ‘With’ and ‘From’ other group members and the accounts related by them

• That you are not as different as you think

• That you are not alone in your thinking

• An entire group can benefit from sharing thoughts and experiences

In addition to Group Therapy you could;–Engage in Individual Therapy – Combined Individual Therapy and Group Therapy–Engage in Couple Therapy–Engage in Family Therapy–Receive medication–Have a combination of the above

Analytic Group Psychotherapy will help you to enhance your self awareness of psychodynamics in all types of groups.

This includes Psychodrama Groups, Behavioural Groups, Family Therapy Group, Organizational Groups, Groups for Children, Adolescents, Homogenous Groups of clients with certain medical illnesses, Homogenous or Heterogeneous groups of clients with psychological disorders – depression, anxiety, grief reactions, Psychological trauma (homogenous groups preferred), Addictive disorders, first episode Psychosis etc.

Group Therapy

1900 – 1909(1905) Joseph Henry Pratt MGH Boston, tuberculosis patients, focus, support and inspiration.

1920 to 1929(1922) Alfred Adler. Counselling with prison and child guidance populations

1930’sTrigent Burrow. Psychoanalytic Group Analysis

1940 to 19491940’s and World War II seen as beginning of modern work groupKurt Lewin (1940, 1951) founder and promoter of group dynamics and field theory Wilfred Bion (1948) broke away from his Freudian background and highlighted the importance of Group DynamicsSigmund Foulkes (1940 onwards) started a method of Group-Analytic Psychotherapy1941-1942 Moreno founded the American Society of Group Psychotherapy1943 Slavson established the American Group Psychotherapy Association and later the International Journal of Group Psychotherapy (1948)

History of Groups

1960 to 1969

Development in a humanistic-existential orientation.Fritz Perls – Gestalt and Eric Berne – Transactional AnalysisCarl Rogers – Developed the T-group concept to make it more personal ie. “basic

encounter groups”

1970 to 1979

Yalom (1970) Lieberman (1971)

1980 to 1989

Self help groups increased

1992 J.Scott Rutan – Developed the Psychodynamic Model for Groups

History of Groups

i. Clinical Training in Group Psychotherapy

A. An engagement in Experiential Groups of staff members only is an excellent clinical exercise in “Attunement” (tuning in with), “Containing” emotions of oneself and others, “Holding” keeping together without fragmentation. This should be with an experienced Group Leader.This will then help the staff in their work;a) with clients to be able to do the same.b) with relatives of patients.c) to avoid burn out themselves.

B. Supervision by an experienced Group Leader.

The Australian Association of Group Psychotherapists offers an intensive 4 year training program, for membership of the Association. This can be reduced in duration as appropriate.

ii. Theoretical Training in Group Psychotherapy in Australia

Group as a System

A. Basic Concepts.1. System - a structure composed of a whole and its parts.

2. Boundary3. Opening / Closing / Permeability4. Autonomy5. Hierarchy6. Homeostasis – ability to maintain internal equilibrium7. Specialization – components lower in hierarchy may develop specialised functions that contribute to higher goals.

B. System Structure.1. External Group Boundary2. Leadership Boundary3. Therapist Boundary4. Personal Boundary of the individual member5. Interpersonal Boundary6. Internal Boundary7. Subgroup Boundary

Curative Factors in Groups through understanding oneself and our roles in society

(Adapted from Irvin Yalom and Claudio Neri with inclusions by Sabar Rustomjee)

1. Hope2. Universality leading to Normalisation3. Ventilation4. Developing a sense of self, of being a person with a right to exist5. To develop a sense of belonging6. To develop independent thinking whilst being in a group7. Developing spontaneity8. Learning from experience9. Learning through being exposed to a Corrective Emotional Experience where

appropriate10. Psycho-education where appropriate in educational groups11. Altruism as applicable to the role of the conductor and the role of the group member

12. Understanding Family Interactions and PsychodynamicsRelating it to group Interactions Relating it to Society and Work Interactions

13. In Analytically orientated groups, understanding the Freudian Unconscious and social UnconsciousTransference and Counter TransferenceAttacking Myths and attacking ShameDifferentiating between the Public Face and Private Inner Self

14. Understanding Introjection, Projection, Denial, Splitting, Intellectualization, Rationalisation, reasons for overprotection etc in an analysis framework

15. Developing sharing and patience16. To be able to live in a space, which is not always clear or well defined17. To engage in reciprocity and the capacity to invest in the individual and the group18. Understanding non-compliance19. Preparations for future choices in life

Curative Factors in Groups through understanding oneself and our roles in society

(Adapted from Irvin Yalom and Claudio Neri with inclusions by Sabar Rustomjee)

Roles of a Group Convenor

• To create a Potential space – a Container in which group work can be done.

• Non-Directive although capable of assuming leadership– To remain disengaged and hence, objective– To enable people to learn a dialogue– Group work is Observation, Thinking, Reflecting and Relating– To convert mindlessness into understanding and meaning. ie to promote

shared new meaning– To keep boundaries– To encourage every group to develop its own legitimacy, its own

uniqueness, its focus and its dynamics

• Time• Place• Criteria for inclusion to the Group• Guidelines – what will be valuable, acceptable and productive• Guidelines regard emergency and routine contacts outside group

hours• Who is welcome to the group eg. Inclusion of children, spouses,

etc.• Confidentiality• Limits – what limits are unacceptable with regards to conduct• What would lead to non-entry to the group – temporary or

permanent

Framework or Boundaries

The common Ego Ideal (Ideal of AIMS) the group OR can be the Ideals of the Group Leader

Group Dynamics – Essential for productive groups - adapted from

S. Freud.-Identification. Std ed. 8. P116.• To recognise all Group members need to be treated alike – with equal love

eg. In the church or the army

Member

Egos of all members. Separate and also in communication

• Each member’s Ego Ideal can become the Collective Ideal for the group

• Individuality is maintained in their egos and needs to be maintained

• Ego Ideal needs to feed back into their separate egos• Ideals that can be reached – that are appropriate, are beneficial

Group Dynamics – Essential for productive groups

Wilfred Bion’s 3 Basic Assumptions

A) Basic Assumption DependencyB) Basic Assumption Fight – FlightC) Basic Assumption Pairing

When these are able to be overcome then the Work Group which can bear pain and work to accept the realities of life, can begin.Earl Hopper has in addition described the 4th Basic Assumption namely Incohesion: Aggregation/Massification or basic assumption I;A/M.He states that aggregates and masses are two most simple primitive social formations. He describes features of both. He describes both having survival value and that the social pattern of a flock of flamingos is analogous to that of say a social mass of a herd of walruses.

Foulksian Group Analytic Concepts as developed by

Sigmund FOULKES, E. J. Anthony , Earl Hopper, Malcolm Pines and Farhad Dalal.

Foulkes believed that psychology is neither Individual nor Group except by abstraction. Although symptom tolerance of any given culture may be considerable, it will fall far below the tolerance of a group analytic therapeutic situation.( E.J.Anthony.)

According to Foulkes the Aim of Group Analysis is to establish harmony between the Individual and the world- not Conformity.

The group functions as a ‘hall of mirrors ’ where resonance of thoughts occurs between group members. The thoughts of each group member in the group, will reverberate/ resonate with some aspect of the group theme which is discussed in the’ here and now’ of the group, and becomes linked with what is uppermost in her or his mind. When verbalized in the group, by the member, it may be interpreted appropriately.The Group Matrix is described by Foulkes as the ‘hypothetical web of communication in a group.’

The symbolic value of the group in the form of a circle is described aptly by Dalal who states:‘To give a simple example ..the Circle has an inside, an outside and a boundary. The inside needs both the outside and the boundary to give it existence. Remove the inside and the circle collapses till there is nothing. Remove the outside and the circle expands until there is everything and thus nothing. Hence all 3 are interrelated and none can exist in isolation from the others.’

He then follows it by describing Foulkes’ radical ideas openly leading to greater understanding of group analysis. He describes Foulkes’ description of ‘inner process’ as in fact being internalized group dynamics. He clarifies that according to Foulkes, the ‘ Foulksian neonate is born into certain mechanisms and forces which it then introjects. The direction being from outside to inside.This is a different concept from the Kleinian infant using elements of its internal world to structure its external world.’

As in Yalom’s Curative Factors, Foulksian group analysts highlight the importance of Hope in group work.

Foulksian Group Analytic Concepts as developed by

Sigmund FOULKES, E. J. Anthony , Earl Hopper, Malcolm Pines and Farhad Dalal.

The Social UnconsciousFoulkes concept of the Social Unconcious is further developed by Earl Hopper, Malcolm Pines and Farhad Dalal among others.

Foulksian analysts state that the individual is ‘embedded in the social and that the individual is also permeated by the social.’ This they claim differs from the concept of the Freudian unconscious in the id, being both repressed and unconscious.

Hopper describes clinical work occurring in both Time and Space in four related areas, namely;The here and now.The here and thenThe there and now and The there and then

Required Relationship with the Convenor/Group

Avoided Relationship with the Convenor/Group

Calamity

• Idealise the group to AVOID attacking the group

• The Required Relationship is primarily defensive

• Therapist needs to interpret the Common Group Tension

Common Group Tension by H.Ezriel

Common Group Tension in Patient’s Group (H.Ezriel)

Required Relationship with the Convenor/Group

Avoided Relationship with the Convenor/Group

Initial 0-8 sessions of Defensive material reveal:

• Passivity, Dependency and Outward over Compliance – with the false image of an “ideal” patient

These lead to:

• Rationalisations and masking of internal conflicts.

•Splitting of good/bad – Convenor and patient being the good ones

•Lack of authenticity

Calamity

• Fear of total abandonment similar to childhood experiences of deprivation. Fears that it will be repeated in the “here and now”

• To avoid Ext. Reality with loss of control

• To avoid experiencing of negative transference with feelings of rejection and helplessness and feelings of aggression towards staff and partners

•TO ADMIT TO REBELLION AND NON COMPLIANCE

D. Stock Whitaker and Libermann – Focal Conflict Theory

Group Solution Disturbing Motive

Reactive Motive

Group solution has a defensive and enabling function

Exclusion Criteria – Contraindications for Group Therapy.a) Protection of the Group

1. Adherence to the Group Contract - may not be possible2. Physically dangerous

b) Efficacy for the specific individual.1. Crisis cases – need individual attention before the client may be suitable for group2. Limited Ego strength with regressive pull3. Impulsive – non controlled with “acting out”4. Life style factors preventing attendance eg. Pilots, nurses traveling a lot5. Acute psychosis6. Not adequately psychologically minded – prefers biological treatment rather than

psychological7. Severe somatisation when confronted with psychological issues in a group8. Paranoid style of responding9. Brittle denial10. Antisocial personality – lack of empathic capacity11. Primitive character pathology

Selection and Exclusion Criteria for Group Treatment

Questions worthy of contemplation before starting a client in a group.1. Is this the right patient for the group?2. Is this the right group for this patient?3. Am I the right therapist for this patient?4. Is this the right time for this person to join this group?5. (He) Why has person not engaged in a group previously or failed to attend (if he/she

has been in a group)

Preparation of Patients for Group Therapy (Rutan & Stone 2001)A. Bonding – Getting to know the patient apart from the group . Building a beginning

allianceB. Evaluation : Factors to asses an Individual forC. Specific tasks for preparation

Selection and Exclusion Criteria for Group Treatment

Types of Groups

• Small

• Medium

• Large

Group Interventions for Treatment of Psychological Trauma

• Module 1 : Group Intervention for Treatment of Trauma in Adults• Module 2: Group Intervention for Treatment of Trauma in Children• Module 3: Group Intervention for Treatment of Trauma in Adolescents.• Module 4: An Overview of Evidence-based Group Approaches to Trauma with Adults• Module 5: An Overview of Evidence-based Group Approaches to Trauma with

Children and Adolescents• Module 6: The Later Stage: The Role of Group Interventions in Coping with the

Aftermath of Traumatic Events• Module 7: Countertransference: Effects on the Group Therapist Working with Trauma• Module 8: Unique Aspects of Group work with Trauma• Module 9: Identification and Management of Masked Trauma Reactions in Groups• Module 10:Group Interventions for Bereavement Following Traumatic Events

These Modules are compiled by the American Group Psychotherapy Association 2004

Brief History of Group Therapy

Early Writings1. Le Bon (1920) The Crowd: A study of the Popular Mind. “Once individuals become

part of a crowd, a type of hypnotic power engulfs them……Individuals loose their sense of responsibility and a group mind assumes control.” These factors contribute to the ‘diminishment of human functioning’

- sense of increased strength, even invincibility- contagion overtakes- suggestibility is greatly increased

2. McDougall (1920) The Group Mind. Discusses that groups can also enhance the individual’s behaviour through organization

3. Freud (1921) Group Psychology and the Analysis of the Ego.

Modern Theories – Group as a Whole

i. a) Group as a Whole approaches (Bion 1960). Experiences in Groupb) Turquet (1974). Oneness.c) Hopper (1997). Incohesion: Aggregation / Massification

ii. Ezriel.H. (1973). Psychoanalytic Group Therapy

iii. Foulkes (1948). Introduction to Group Analytic Psychotherapy

iv. Whitaker and Lieberman (1958, 1964). Psychotherapy through Group Process.

Yalom’s interpersonal Theory (1995) ‘The Theory and Practice of Group Psychotherapy’.The major thrust for change occurs in the group interaction as it occurs in the here and now, maladaptive transactions are observed and interpreted, a corrective emotional experience is created, with an appropriate group culture, and concentration or the nature of the feedback.

Modern Theories – Interpersonal Theories

The Psycho-dynamic Model and Groups (Rutan 1992)

A. Level of Intervention1. Past – (here and now) – Future2. Group-as-a-whole – Interpersonal – Individuals3. In Group – Out group4. Affect – Cognition5. Process – Content6. Understanding – Corrective emotional experience

B. Avenues into the unconscious1. Transference2. Counter transference

3. Free Association

Brief History of Group Therapy and Modern Theories are as per American Group Psychotherapy Association’s Manual – Principles of Group Psychotherapy

Self Help Groups

Self Help Groups process is a NON DIRECTIVE, NON-THREATENING process of RE-ORIENTATION occurring within a SAFE, COMFORTABLE and REASSURING HUMAN GROUP emphasizing the importance of mutual aid.

They are a formalized mutual help network whose members share a specific problem

Aims of Self Help Groups1. Behavioural Change – eg. Alcoholics Anonymous, Weight Watches,

Gamblers Anonymous2. Groups concerned primarily with enhancing primary care – Self Help Groups

associated with chronic illnesses, Blindness, Deafness, Arthritis, Diabetes, M.S., Muscular Dystrophy, Motor Neurone Disease, Lupus, Cystic Fibrosis, etc.

3. Groups concerned primarily with providing Social Support and new coping strategies – Alanon, P.W.P, Grow etc, Alzheimers Support Group, Stroke Support Centre, P.R.O.P

4. Groups concerned with Rehabilitation – Self Help Groups within the Schizophrenia Fellowship, Anorexia and Bulimia Foundation, Obsessive Compulsive Disorder Foundation, Vic Autistic Child and Adult Association

5. Self Help Groups concerned with Social Survival eg. Different women’s groups, groups for Gay Activists

6. Self Help Groups concerned with personal growth and self actualization.

Enquiries.

For all enquiries and purposes of circulation, correspond with Dr Sabar Rustomjee Email ; sabar@iprimus.com.auPostal address. 1A Erica AvenueMalvern EastVic 3145Australia

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